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Medicaid Autism Spectrum
Disorder (ASD)Services for
Children
Policy Discussion1:00 P.M. – 3:00 P.M.
Cannon Building Room 125
March 31, 2015
Public Input Opportuntities
• Meeting today is about DRAFT policy
• Copy of draft policy and today’s presentation are
listed on Medicaid websites at:
• health.utah.gov/ltc/asd
• health.utah.gov/autismwaiver
• Options for submitting comments
– Online, Mail or Fax
• Join listserv on Autism Waiver site
• Medicaid ASD Services Advisory Committee to
develop additional procedural/policy detail
2
History of Medicaid ASD
Coverage Policy
CMS ASD related services policy
– Historically coverage through HCBS waivers
–Target populations
–HCBS waiver eligibility
– Disregard of parent/family income and assets
–Capped enrollment
– July 2014 CMS ASD related services guidance
–Open to all EPSDT (CHEC) eligible clients
–No caps on enrollment
–Community Medicaid eligibility rules apply3
Guiding Principles for ASD
Services Policy Development
– Medically Necessary Services
• Appropriate comprehensive assessment and
diagnosis
• Individualized treatment plan
– Ongoing evaluation of treatment efficacy
– Cost Effective Services
• Ensure private insurance (if available) is primary
payer
• Develop appropriate reimbursement rates
– Evidence-based, Quality Services
• Available statewide
– Qualified, Experienced Providers 4
Guiding Principles for ASD
Services Policy Development
• Encourage parent and family involvement for
better outcomes
• Ensure smooth transitions for children served in
Medicaid Autism Waiver and their families and
providers
• Agency collaboration with stakeholders
• Public meetings
• Public comment opportunities
• Possible development of Medicaid ASD Services
Advisory Committee
5
Impact on Medicaid Autism
Waiver
Current Medicaid Autism Waiver Clients• 296 children (2 through 6) currently in services
• Continue waiver until age-out of current enrollees
• Transition from ABA as waiver service to EPSDT (CHEC)
service
• Staged Transition
– Children turning 7 will be evaluated for traditional Medicaid eligibility
– Transition one provider at a time
• Grandfather initial enrollment requirements
• Medicaid and DSPD staff to work closely with families and
providers
• Provider training on prior authorization and billing6
Key Draft Policy PointsEligibility
• Services Only Available to Traditional Medicaid
Clients under 21 (EPSDT Section of State Plan)
• Must meet community Medicaid financial eligibility
• Must have an ASD diagnosis
• Physician or psychologist to render diagnosis
• Require use of specific diagnostic tools
• Autism Diagnostic Interview-Revised (ADI-R)
• Autism Diagnostic Observation Schedule (ADOS)
• Autism Diagnostic Observation Schedule, 2nd Edition (ADOS-2)
• Pre-linguistic Autism Diagnostic Observation Schedule (PL-ADOS)
7
Key Draft Policy PointsService Delivery
• Fee-for-Service (FFS) Payment
– Diagnostic evaluation
– Applied Behavior Analysis (ABA) services
– ASD related medical services (PT,OT,ST, etc.) for
clients not enrolled in Accountable Care
Organizations (ACO)
• ACO – coverage for ASD-related PT, OT, ST etc.
• Prepaid Mental Health Plans (PMHP) –
coverage for co-occurring mental health
conditions
8
Key Draft Policy IssuesProvider Qualifications
• ABA service must be rendered by, or under direction of,
BCBA-D or BCBA (Behavior Analyst)
• Behavior Analysts enrolled in Masters or Doctoral BA Program
• Details of requirements still to be determined
• Licensed and certified behavioral analysts must design
treatment plans and supervise BCaBAs and Technicians
• State licensing requirement effective fall 2015 (Transition period)
• Registered Behavior Technician
• As per Behavior Analyst Certification Board (BACB) requirements
• Transition period for direct service workers currently providing
services in Medicaid Autism Waiver and newly hired technicians
• Background check requirements
9
Key Draft Policy IssuesBehavior Analyst Supervision
• Provide (direct and indirect) supervision of each child’s case
that amounts to 10% of the time the child is receiving direct
services from a BCaBA or Technician
• Provide direct supervision that involves observing the
BCaBA or Technician with the child an average of 50% or
more of the monthly supervision required
• Must have knowledge of Technician’s ability to implement
plan
• Rural Areas (Outside Wasatch Front) may provide
supervision to the BCaBA or Technician via HIPAA compliant
remote access technology. (Provider responsible to ensure
HIPAA compliance)
10
Key Draft Policy PointsABA as Primary Covered Service
• ABA is a well-developed discipline based on a mature body
of scientific knowledge and established standards for
evidence-based practice
• ABA is not investigational or experimental
• National Autism Center’s National Standards Report -
treatments categorized as “established”
• ASD Services Advisory Group to review new treatments
• ABA is an effective treatment for EPSDT-aged clients
• Types of ABA - Focused and Comprehensive – address different
goals based on needs of the child
• Comprehensive – Example - Early Intensive Behavioral
Interventions (EIBI) for young children
• Adaptive Behavior Treatment - social skills groups11
Key Draft Policy PointsNon-Covered Services Examples
• ABA services rendered when measurable functional improvement is not
expected or progress has plateaued
• Services that are investigational, this includes treatments for which the
efficacy has not been firmly established by significant empirical study
• Services that are primarily educational in nature
• Services that are vocationally or recreationally-based
• Custodial or respite care services
• Services, supplies, or procedures performed in a non-conventional
setting including, but not limited to: resorts; spas; therapeutic programs;
and camps
• Time spent by the BCaBA or Technician charting or collecting data that
is occurring separate from the time spent documenting direct observations
that occur when the provider is working directly with the child
• Provider’s time traveling to get to client’s home or other community
setting
• Transportation of the child 12
Key Draft Policy PointsService Settings
• Services in School-based Settings
– Only ASD related services identified on an IEP or IFSP
may be provided in school-based settings.
– ASD related services identified on an IEP or IFSP must
be provided through the Medicaid School-Based Skills
Development Services benefit.
• With exception of the Behavior Analyst’s participation in the child’s
annual IEP development meeting, the Medicaid agency will not
reimburse fee-for-service ABA services in school-based settings that
are in addition to services listed on an IEP.
– If the Behavior Analyst’s participation in annual IEP
meeting is deemed medically necessary, the provider may
bill for this specific service on a fee-for-service basis. 13
Key Draft Policy PointsService Settings
• Services in Home, Community, Clinic or Center-
based Settings
– ABA services can be delivered in a variety of relevant
naturally occurring settings in the home and community
including targeted settings. Services can also be
delivered in clinic or center-based settings.
14
Key Draft Policy PointsMultiple Provider Coordination
• Clients can access multiple providers concurrently,
particularly for the purpose of receiving services in
multiple settings. For example, one provider specializes
in center-based services and one provider specializes in
in-home services
• In all cases, providers may not subcontract with another
ABA provider and may not bill on another provider’s
behalf
• Providers cannot require a client to receive services
from a specific provider for perceived “treatment
compatibility” or any other purpose
15
Key Draft Policy PointsRestrictive Interventions
• Medicaid agency working on policy details
• “Restrictive interventions may be necessary on rare
occasions with meticulous clinical oversight and controls”
• ASD Services Advisory Group to assist with policy
development
16
Key Draft Policy PointsCovered ABA Service Codes
Code Service Provider
0359T Behavior Identification Assessment (untimed) BCBA-D or BCBA
0364T Adaptive Behavior Treatment by Protocol (first 30 minutes) BCaBA or Technician
0365T Adaptive Behavior Treatment by Protocol (each (+) 30 min) BCaBA or Technician
0366T Group Adaptive Behavior Treatment by Protocol (first 30 minutes) BCaBA or Technician
0367T Group Adaptive Behavior Treatment by Protocol (each (+) 30 min) BCaBA or Technician
0368T Adaptive Behavior Tx w/ Protocol Modification (first 30 minutes) BCBA-D or BCBA
0369T Adaptive Behavior Tx w/ Protocol Modification (each (+) 30 min) BCBA-D or BCBA
0370T Family Adaptive Behavior Treatment Guidance (untimed) BCBA-D or BCBA
0371T Multiple Family Adaptive Behavior Treatment Guidance (untimed) BCBA-D or BCBA
0372T Adaptive Behavior Treatment Social Skills Group (untimed) BCBA-D or BCBA17
Key Draft Policy PointsABA Service Limits
Code Service Limits
0359T Behavior Assessment 1 per Every 180 Days
0364T / 0365T Treatment by Protocol 20 Hours per Week
0366T / 0367T Group Treatment by Protocol 2 Hours per Week
0368T / 0369T Treatment with Protocol Modification60 Hours per Every 180
Days
0370T / 0371T Family Treatment Guidance3 Episodes per Every
180 Days
0372T Social Skills Group 2 hours per Week
18
Key Draft Policy PointsABA Reimbursement Rates
Code Service Rate Rate Type
0359T Behavior Assessment $160.00 Encounter
0364T / 0365T Treatment by Protocol $15.00 30 mins
0366T / 0367T Group Treatment by Protocol See Group Rates* 30 mins
0368T / 0369T Treatment with Protocol Modification $40.00 30 mins
0370T Family Treatment Guidance $40.00 Encounter
0371T Multiple Family Treatment Guidance See Group Rates* Encounter
0372T Social Skills Group See Group Rates* Encounter
*Group rates are based on the modifier billed. Per child reimbursement is reduced
when services are offered in groups. See full policy document for groups rates.
Proposed rates are based on rates paid for similar services in
the Autism Waiver.
19
Questions & Answers
• Questions from stakeholders
• Questions for stakeholders
20
Next Steps
• Finalize ASD related services provider manual
• Draft administrative rule
• Update member guide, and EPSDT guide
• Publish parent and family ASD services guide
• Train Medicaid health program representatives,
eligibility workers, and customer service staff
• Work with CMS on transition plan for waiver clients
• Complete programming changes for new codes and
rates
• Develop specific transition timeframes for individual
children, families and providers 21
Public Comment Submission
Submit Comments:
Medicaid Websites:
health.utah.gov/ltc/asd
health.utah.gov/autismwaiver
Mail: Utah Department of Health
Division of Medicaid and Health Financing
Attn: ASD Services Policy Comments
PO BOX 143112
Salt Lake City, UT 84114-3112
Fax: 801-323-1588
Email questions to: [email protected]